RHONDA LUCAS SICU, RASHID HOSPITAL JUNE, 2011

ABG INTEPRETATION By the end of this module you will be able to Identify the components of the ABG Interpret ABG values Identify the major causes of acid-base abnormalities Describe interventions to correct acid-base abnormalities INTRODUCTION A key component in critical care nursing is being able to understand ABG results. This self-learning package will help you to analyze ABG results and describe actions the healthcare team can take in order to correct acid-base disturbances. THE ACID-BASE SYSTEM The main components in the acid-base system are CO2, an acid, and HCO3(or bicarb), a base. As with other systems in the body, the trend is toward equilibrium or a neutral state. The body frequently attempts to compensate for its imbalances by making adjustments in the other direction (think of tachycardia as a response to low cardiac output). It is the same with the acid-base balance if a person has a metabolic acidosis the respiratory system will try to compensate by the patient breathing faster to blow off some of the CO2. There are two systems in the body responsible for maintaining acid-base balance: 1. Respiratory System: By changing the rate of respirations, you can either retain or blow off CO2. The respiratory rate is a rapid compensator (minutes). 2. Renal System: The kidneys rid the body of various acids (H+) in an effort to maintain a constant bicarb. It will retain bicarb if it is needed to compensate for an acidotic imbalance in the body, and vice versa. The renal system is a very slow compensator (several hours to several days). There are 4 categories of acid-base disturbances in your body. Regardless of the problem, however, treatment is always aimed at resolving the underlying problem. 1. Respiratory Acidosis: Always caused by hypoventilation but the causes of hypoventilation can be numerous (narcotics, cracked ribs, lung disorders, etc.) Treatment is to increase the respiratory rate

and/or effort by addressing the underlying problem (lower the narcotic rate, bind the ribs, excise the tumour, treat the COPD, etc.) 2. Respiratory Alkalosis: Caused by hyperventilation (pain, fever, pneumonia, heart failure). Treatment is to decrease the respiratory rate/effort by, once again, addressing the underlying cause. 3. Metabolic Acidosis: This state is caused either by an increase in H + or a loss of HCO3- (increased catabolism, bicarb loss through diarrhea, starvation, renal failure). Treatment requires you to either excrete the buildup of acids or retain bicarb. You do this how? You guessed it: By addressing the underlying problem! 4. Metabolic Alkalosis: This is caused by a loss of H+ or a retention of bicarb (loss of potassium through diarrhea or gastric losses, renal failure). Treatment is addressed once again at fixing the underlying problem (replacing potassium losses, administering Diamox to flush out the bicarb, etc.). ANALYZING ABGs Become familiar with normal values for ABGs. pH 7.35 7.45 PaCO2 35 45 PaO2 80 100 HCO322 26 SaO2 90% Base Excess -2 to +2

If you approach ABG Interpretation systematically, you cant go wrong. You have to look at each component one at a time. Always follow these steps in order: 1. Look at the pH: This is the crucial step because all other interpretations are dependent upon the pH. Is it normal? Is it low? Is it high? 7. 35 7. 45 < 7.35 (Acidosis) > 7 45 (Alkalosis)

Keep in mind: If the pH is 7.35 7.39 your patient is closer to acidotic than alkalotic If the pH is 7.41 7.45 your patient is closer to alkalotic than acidotic

2. Look at the PaCO2: We now need to determine whether the abnormality is caused primarily by respiratory or metabolic issues: If the PaCO2 change is in the opposite direction as the pH (pH goes lower while PaCO2 goes higher) then the cause is primarily respiratory. Ex. pH = 7. 32 PaCO2 = 48 The pH is going down but the PaCO2 is going up, so this is primarily a respiratory acidosis. If the PaCO2 is in the other direction, then the imbalance is primarily metabolic in nature. 3. Look at the HCO3-: If the bicarb is in the same direction as the pH (pH and bicarb both go up) then the cause is primarily metabolic. Ex. pH = 7.32, HCO3- = 19 Both the pH and the bicarb are acidotic; therefore, the acidosis is metabolic in nature. Here is a chart to help you:

Lets see how this works. Using the steps above, interpret the following abgs: 1. pH 7.22 PaCO2 55 HCO3- 25 The pH is going down; the PCO2 is going up and the HCO3- is normal. This is respiratory acidosis 2. pH 7.50 PaCO2 42 HCO3- 33

The pH is up; the PaCO2 is normal but the bicarb is trending up. This is metabolic alkalosis

COMPENSATION The examples above are fairly straightforward. Now lets complicate matters a bit. What happens when an acid-base imbalance exists over a period of time? The body tries to compensate for that. So, an ABG result can reflect uncompensated, partially compensated or fully compensated conditions When an acid-base disorder is either uncompensated or partially compensated, the pH remains outside the normal range. In fully compensated states, however, the pH has returned to within the normal range, even though the other values may still be abnormal. Be aware that neither system has the ability to overcompensate. If you look back to the examples above, these patients are uncompensated because the pH is outside normal limits. The primary cause of the imbalance is easily identified because the compensatory buffering system (ie either the PCO2 or the HCO3-) remained in the normal ranges, not adjusting itself to restore balance. So lets now look, then, at ABGs which have evidence of partial compensation. The same steps apply: 1. Assess the pH. This step remains the same and allows us to determine if an acidotic or alkalotic state exists. Recall that even when the pH is within normal range, depending on whether it is above or below 7.40, your results will usually favour acidosis or alkalosis. 2. Assess the PaCO2: In an uncompensated state, we have already seen that the pH and PaCO2 move in opposite directions when indicating that the primary problem is respiratory. But what if the pH and PaCO2 are moving in the same direction? That is not what we would expect to see happen. We would then conclude that the primary problem was metabolic. In this case, the decreasing PaCO2 indicates that the lungs, acting as a buffer response, are attempting to correct the pH back into its normal range by decreasing the PaCO2 (blowing off the excess CO2). If evidence of compensation is present, but the pH has not yet been corrected to within its normal range, this would be described as a metabolic disorder with a partial respiratory compensation.

3. Assess the HCO3: In our original uncompensated examples, the pH and HCO3 move in the same direction, indicating that the primary problem was metabolic. But what if our results show the pH and HCO3 moving in opposite directions? That is not what we would expect to see. We would conclude that the primary acid-base disorder is respiratory, and that the kidneys, again acting as a buffer response system, are compensating by retaining HCO3, ultimately attempting to return the pH back towards the normal range.

These tables will help you understand the relationships: FULLY COMPENSATED

PARTIALLY COMPENSATED

Notice that the only difference between partially and fully compensated states is whether or not the pH has returned to within the normal range. In compensated acid-base disorders, the pH will frequently fall either on the low or high side of neutral (7.40). Making note of where the pH falls within the normal range is helpful in determining if the original acidbase disorder was acidosis or alkalosis. Lets try some examples: 1. pH 7.32 PaCO2 32 HCO3- 18 This patient is acidotic; normally you would expect the PCO2 to be high as well, but it is not. Therefore, the acidosis is primarily metabolic in origin. The low PaCO2 indicates that the lungs are trying to compensate for the metabolic acidosis. However, the pH still remains out of normal range, so this is a partially compensated metabolic acidosis. 2. pH 7.35 PaCO2 48 HCO3- 28 The pH is on closer to acidosis than alkalosis (low normal). The PaCO2 is high, suggesting a respiratory acidosis. The bicarb is high as well, suggesting it is compensatory. Because the pH is normal, though, this is a fully compensated respiratory acidosis.

3. pH 7.43

PaCO2 48 HCO3- 36

The pH is the high side of normal so closer to alkalosis. The high PaCO2 suggests acidosis though. The bicarb, however, is high and so the PaCO2 must be compensatory. This is a fully compensated metabolic alkalosis. 4. pH 7.33 PaCO2 62 HCO3- 35

Can you tell what this one is? MIXED DISTURBANCES So far these examples show a clear picture one way or the otherwhat about the cases when both the PCO2 and the bicarb are abnormal, but in opposite directions? How do we know which one is causing the acidosis/alkalosis? The answer is that both are contributing to the imbalance. We call these cases mixed respiratory and metabolic acid-base disorders. Remember: Compensation for simple acid-base disturbances always drives the compensating parameter (ie, the PaCO2 or HCO3-) in the same direction as the primary abnormal parameter (ie, the HCO3- or PCO2 ). For example, if the pH is high and the PaCO2 is high, and the bicarb is high, then this would be a partially compensated metabolic alkalosis, with the high PaCO2 being the compensatory component. But what if the pH is high, the PaCO2 is low and the bicarb is high? Whenever the PCO2 and HCO3- are abnormal in opposite directions, ie, one above normal while the other is reduced, a mixed respiratory and metabolic acid-base disorder exists. A simple Rule of Thumb:

When the PCO2 is elevated and the [HCO3-] reduced, respiratory acidosis and metabolic acidosis coexist. When the PCO2 is reduced and the [HCO3-] elevated, respiratory alkalosis and metabolic alkalosis coexist

In acidosis we are base deficient so SBE will be negative. In alkalosis we are base excess so SBE will be positive.

But is there one component contributing more than another? There may be. How can you tell?

This is when we have to look at the base excess (also known as standard base excess or SBE). If the SBE is in the same direction as the pH (ie both acidotic or both alkalotic), then the cause is metabolic. If the SBE is not in the same direction as the pH, then the primary problem is respiratory. So lets look at an example: 1. pH 7. 52 PaCO2 27 HCO3- 29 This is clearly an alkalosis because the PaCO2 and the bicarb both trend in that direction so there is a mixed picturewhich one is the primary cause and which one is the compensation? We wont know until we look at the Base Excess (also known as Standard Base Excess, SBE). If the SBE in this case were a positive number, positive suggests there is base excess, so the primary cause of the alkalosis is metabolic. If the SBE were negative this would indicate there is a deficit of base; because base causes alkalosis, if there is a deficit the primary cause of the alkalosis would therefore have to be respiratory. 2. pH = 7.32 PaCO2 = 48 HCO3- = 19 In this case, everything is acidotic and we dont know whether the cause is metabolic or respiratory. So we must look at the SBE. SBE = -0.6 This SBE is acidotic (negative number, suggesting a base deficit), so the primary cause of the acidosis is metabolic. If the SBE was positive this would indicate there is an excess of base; an abundance of base cannot cause acidosis; therefore, the acidosis would be respiratory. And thats all there is to know about ABGs!!! There is an ABG Interpretation Quiz in the next clear sheaf. Try to complete the quiz. The answers are attached at the back.